Comparison Between Sinus Tarsi Approach and Extensile Lateral Approach for Treatment of Closed Displaced Intra-Articular Calcaneal Fractures: A Multicenter Prospective Study

doi:10.1053/j.jfas.2015.11.008

The Journal of Foot and Ankle Surgery

Volume 55, Issue 3, May–June 2016, Pages 513-521

https://doi.org/10.1053/j.jfas.2015.11.008 Get rights and content

Abstract

The purpose of our investigation was to prospectively review and compare the early outcomes of Sanders II and III closed displaced intra-articular calcaneal fractures (DIACFs) in a group of patients treated by open reduction and internal fixation with plate and screws using the extended lateral approach or the sinus tarsi approach (STA). Thirty-eight patients with DIACFs were prospectively enrolled and operatively treated using either the extended lateral approach or the STA. Patients underwent a careful clinical and radiographic examination and were evaluated according to the American Orthopaedic Foot and Ankle Society score, visual analog scale, and the Foot Function Index. The results from our study showed similar clinical and radiographic outcomes between the 2 groups. In our series, Sanders II and III DIACFs were sufficiently exposed using the STA to achieve anatomic reduction and stable fixation. The STA group had a lower incidence of wound complications (p ≥ .05), the surgical procedure was faster, and the waiting time to surgery was shorter (p ≤ .05). Despite the limited number of patients and the short follow-up period, our results suggest that the STA is a useful method for the treatment of DIACFs, with a low incidence of complications and results comparable to those for patients treated using the extended lateral approach.

Section snippets

Patients and Methods

We performed a multicenter prospective study of patients affected by DIACFs who had been treated operatively from January 2012 to December 2012. The patients were enrolled in the study consecutively and divided into 2 groups. Group 1 was treated at Ospedale San Camillo-Forlanini di Roma (hospital 1) and had undergone ORIF of the DIACF through the ELA. Group 2 was treated at Ospedale Civile di Bracciano (hospital 2) and had undergone ORIF of the DIACF through the STA. The protocols were

Results

The 2 groups were comparable with regard to the demographic data (i.e., age, male/female ratio, activity level; p > .05; Table 1). The average AOFAS hindfoot score was 81.95 ± 10.89 for the ELA group and 82.17 ± 11.50 for the STA group. In the ELA group, the average FFI score was 17.85 ± 11.03 and was 18.39 ± 12.67 in the STA group. The mean VAS score (considering the mean morning, activity, and end of day VAS score) was 22.75 ± 13.71 in the ELA group and 21.29 ± 15.56 in the STA group. The

Discussion

The purpose of our investigation was to prospectively review and compare the early outcomes of Sanders II and III closed DIACFs in a group of patients treated by ORIF with plate and screws through the ELA or STA. Our hypothesis that no outcome differences would be detected when using the 2 different approaches was only partially confirmed by the results of the present investigation. Our results suggest that the quality of reduction, stability of the internal fixation, and functional outcomes

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Cited by (70)

Postoperative complications after displaced intra-articular calcaneal fracture operations
2024, Foot and Ankle Surgery
The objective was to compare postoperative complications in the management of displaced intra articular calcaneal fractures (DIACF) between two groups; the open reduction and internal fixation (ORIF) group versus the percutaneous fixation (PF) group.
A total of 243 DIACFs were diagnosed and 127 of them received operations either with ORIF 75 (59.1 %) or PF 52 (40.9 %) between 2004 and 2018. Postoperative complications, radiological Sanders’s classification and improvement of Böhler’s angle were analyzed.
Early complication rate (<6 weeks), rate of deep wound infections and wound edge necrosis were significantly better in PF than in ORIF patient group. There were no significant differences in late complications (>6 weeks from operation) nor in improvement of Böhler’s angle.
Complication rate is lower when using PF technique while fracture reduction remains the same compared to the ORIF.
IV retrospective cohort study at a single institution.
Percutaneous fixation of displaced intraarticular fractures of the calcaneus. A retrospective case series study and a review of the literature
2023, Injury
To evaluate the outcome of displaced intraarticular calcaneal fractures (DIACFs) of a case series of patients who were treated with a percutaneous fixation technique.
Eight patients were operated for DIACFs and they were evaluated for the outcome and complications in a mean follow up of 9 months (range: 6 – 12 months). At the last follow up the AOFAS score, the Boehlers’ angle and the presence of any complication were noted. The time from injury to surgery was also reported. The correlation of the AOFAS score and the development of post traumatic subtalar arthritis to the type of fracture, to the post operative Boehler's angle and to the time from injury to surgery were investigated.
The overall mean AOFAS (Americal Orthopaedic Foot and Ankle Society) score was 84,625 (Range: 73 – 96). The mean AOFAS score of type II and type III fractures was 87,667 and 75,500 respectively. The mean AOFAS score for fractures with a postoperative Boehler's angle of less than 10° and more or equal to 10° was 76,750 and 92,500 respectively. This difference was found to be statistically significant. The mean AOFAS score for fractures who were treated less or equal to six days and more than six days post injury was 91,250 and 78 respectively. Two out of four patients with a post operative Boehler's angle less than 10° developed post traumatic subtalar arthritis. No patient out of four for whom a Boehler's angle of more than 10° has been achieved, developed subtalar arthritis. No infection occurred in any of the patients.
Percutaneous fixation is a safe and effective way of treating DIACFs. The outcome is directly related to the quality of reduction, which is significantly dependent to the timing of surgery. The earlier the fracture is operated the better the reduction by closed means is.
Fixation of displaced intra-articular calcaneus fractures is safe using either sinus tarsi or extensile lateral approach
2023, Injury
Management of displaced intra-articular calcaneus fractures continues to challenge surgeons. Use of the extensile lateral surgical approach (ELA) had been standard practice however wound necrosis and infection have become deterrents. The sinus tarsi approach (STA) has gained popularity as a less invasive technique to optimize articular reduction while minimizing soft tissue injury. Our aim was to compare wound complications and infections following calcaneus fractures treated using ELA versus STA.
Retrospective review of 139 displaced intra-articular calcaneus fractures (AO/OTA 82C; Sanders II-IV injuries) treated operatively at 2 level-I trauma centers using STA (n = 84) or ELA (n = 55) over a 3-year period with minimum 1-year follow up was performed. Demographic, injury, and treatment-related characteristics were collected. Primary outcomes of interest included wound complications, infection, reoperation, and American Orthopaedic Foot and Ankle Society ankle and hindfoot scores. Univariate comparisons between groups were conducted using Chi-Square, Mann-Whitney, and independent sample t-tests at the p < 0.05 significance level, where appropriate. Multivariable regression analysis was performed to identify risk factors for poor outcomes.
Demographic characteristics were homogenous between cohorts. Most sustained falls from height (77%). Sanders III fractures were most common (42%). Patients treated with STA went to surgery earlier (6.0 days STA vs 13.2 ELA, p < 0.001). No differences were seen in restoration of Bohler's angle, varus/valgus angle, or calcaneal height, yet the ELA significantly improved calcaneal width (-2 mm STA vs -13.3 mm ELA, p < 0.001). There were no significant differences in wound necrosis or deep infection based on surgical approach (12% STA vs 22% ELA, p = 0.15). Seven patients underwent subtalar arthrodesis for arthrosis (4% STA vs 7% ELA). No differences in AOFAS scores were seen. Risk factors for reoperation included Sanders type IV patterns (OR = 6.6, p = 0.001), increasing BMI (OR = 1.2, p = 0.021), and advanced age (OR = 1.1, p = 0.005), not surgical approach.
Despite prior concerns, use of ELA versus STA for fixation of displaced intra-articular calcaneus fractures was not associated with more complication risk, illustrating both are safe when indicated and executed appropriately.
Sinus tarsi approach in high-risk patients with displaced intra-articular calcaneus fractures: A case series
2022, Journal of Orthopaedics
Though research exists regarding calcaneal fractures, the treatment approach for displaced intra-articular calcaneal fractures (DIACF) remains controversial. The most common approach, the extensile lateral approach (ELA), for the treatment of DIACFs has high rates of wound complications reported. In contrast, the sinus tarsi approach (STA) is becoming more popular due to its minimally invasive technique. The objective of this retrospective study is to investigate the incidence of wound complications in high-risk patients with DIACF following operative fixation via the STA.
Following IRB approval, a retrospective chart review was performed between 2007 and 2013 to assess high-risk patients for the presence of wound complications, including deep infections and delayed wound healing, following the use of STA for the management of DIACF's (n = 36). Demographics, risk factors, and secondary outcomes such as time to surgery were recorded.
Of the 36 high-risk patients included in our study, seven had post-operative complications following operative fixation via the STA. Specifically, four patients had delayed wound healing, and three developed deep infections. Time to surgery had the greatest negative effect on postoperative complications and was influenced by age, sex, and the presence of a concomitant injury.
In conclusion, this study demonstrates that the STA is a viable option for high-risk patients with displaced intra-articular fractures. Additionally, time to surgery should be minimized, when possible, to reduce risks of post-operative complications, including infections and delayed wound healing.
Complications in the Management of Displaced Intra-articular Calcaneal Fractures: A Systematic Review and Network Meta-Analysis of 2538 Patients
2022, Journal of Foot and Ankle Surgery
The purpose of this study was to compare the complication risk of different treatments for displaced intra-articular calcaneal fractures (DIACFs). Randomized controlled trials comparing interventions for DIACFs were included: (1) interventions with conservative treatment, surgery with a minimally invasive approach (MIA) (sinus tarsi or small longitudinal), surgery with a percutaneous approach (PA) and open surgery with the extensive “L” lateral approach (ELA), and (2) complications and wound infections were also assessed. Twenty-six published trials met the inclusion criteria. The trials involved a total of 2538 patients surgically treated for acute DIACFs. For total complications, the mean incidence rate in the ELA was significantly higher than the rates in other treatments (conservative treatment vs ELA: odds ratio (OR), 0.36; p < .001; MIA vs ELA: OR, 0.23; p = .002; and PA vs ELA: OR, 0.18; p < .001). For wound infections, there were no significant differences among the groups (MIA vs PA: OR, 0.98; 95% CI, 0.32-3.01; p = .977; MIA vs ELA: OR, 0.45; 95% CI, 0.19-1.10; p = .081; and PA vs ELA: OR, 0.46; 95% CI, 0.19-1.11; p = .085). According to the surface under the cumulative ranking curve, the PA was most likely to be the best management for minimizing complications (surface under the cumulative ranking curve = 86.2). The ELA was significantly related to a higher risk of complications among all management methods. The PA was most likely to be the ideal choice when only complications were considered.
Modified sinus tarsi approach with a variable-angle locking anterolateral plate for Sanders type II and III calcaneal fractures
2022, Foot and Ankle Surgery
Citation Excerpt :
Due to the high surgical complication rate and the difficulty in predicting surgical results, conservative treatments were generally favoured by surgeons in the past decades [7]. However, since the 1990s, the increasingly detailed understanding of injury mechanisms and improvements in internal fixation devices have increased the interest in open reduction and internal fixation (ORIF), which has gradually gained acceptability for the treatment of DIACFs [2,8–10]. Extensile lateral approach (ELA) is generally considered the gold standard approach for the treatment of DIACFs [11–13], since it provides excellent exposure of the subtalar posterior facet, calcaneocuboid joint, and complete lateral wall [14].
We compared the effectiveness of the extensile lateral approach (ELA) and modified sinus tarsi approach (MSTA) with a variable-angle locking anterolateral plate in treating Sanders type II and III calcaneal fractures.
We reviewed 45 DIACFs treated by a single surgeon from 2017 to 2020. Open reduction using ELA and MSTA was performed in 25 and 20 patients, respectively. Follow-up evaluations included radiological assessments and clinical evaluations.
Pre- and postoperative radiologic parameters for the calcaneus were significantly different. The average American Orthopaedic Foot and Ankle Society scores were 81.24 and 85.00, the mean visual analogue scale scores were 2.28 and 1.65, and the wound-related complication rates were 64.0% and 15.0% in the ELA and MSTA groups, respectively. Bony union was achieved in all cases.
For Sanders type II and III fractures, MSTA seems to be a safer and more satisfactory method, with fewer postoperative complications.

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Original ResearchComparison Between Sinus Tarsi Approach and Extensile Lateral Approach for Treatment of Closed Displaced Intra-Articular Calcaneal Fractures: A Multicenter Prospective Study

Abstract

Section snippets

Patients and Methods

Results

Discussion

Foot (Edinb)

J Foot Ankle Surg

J Foot Ankle Surg

J Foot Ankle Surg

J Foot Ankle Surg

Mini-open sinus tarsi approach with percutaneous screw fixation of displaced calcaneal fractures: a prospective computed tomography base study

Foot Ankle Int

An economic evaluation of operative compared to nonoperative management of displaced intra-articular calcaneal fractures

J Bone Joint Surg Am

Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized controlled multicenter trial

J Bone Joint Surg Am

Displaced intra articular calcaneal fractures: long term outcomes in women

Foot Ankle Int

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J Bone Joint Surg Am

Subtalar fusion after displaced intra-articular calcaneal fractures: does initial operative treatment matter

J Bone Joint Surg Am

Extensive intra articular fractures of the foot: surgical management of calcaneal fractures

Clin Orthop Relat Res

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Br Med Bull

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Original Research
Comparison Between Sinus Tarsi Approach and Extensile Lateral Approach for Treatment of Closed Displaced Intra-Articular Calcaneal Fractures: A Multicenter Prospective Study